Anesthetic management in endovascular treatment of aortic pathologies

Öz

Objective: In this study we aimed to compare the anesthesia methods we used in the endovascular treatment of thoracic and abdominal aorta pathologies and to discuss accompanied by literature. Methods: Our study was carried out be retrospectively assessing a total of 20 patients on whom we had administered endovascular treatment for aortic aneurism and aortic dissection. The demographic features of the patients, their American Anesthesia Association (ASA) scores, laboratory findings, accompanying diseases, whether they smoke, their ejection fraction and the place and type of aortic pathology was recorded. Also the surgical procedure, anesthesia method, the amounts of crystalloids, colloids and blood products used during the surgery, the anesthesia and surgery durations, complications and interventions, duration of stays in intensive care and the hospital in general and the mortality rates were recorded. All cases were provided with standard anesthesia monitoring. Results: A total of 20 (M=15, F=5) cases were included in our study. 16 of our cases were in ASA 3 risk group and 4 were in ASA 4 risk group. While patients who had been administered with thoracic endovascular aortic repair (TEVAR) were all given general anesthesia, seven patients who had been administered with abdominal endovascular aortic repair (EVAR) were given regional and 6 were given general anesthesia and one case was only given sedoanalgesia. While 8 of the patients administered with EVAR had hypertension all of the patients administered with TEVAR had hypertension. No significant differences were found in blood and blood product transfusions, preoperative and postoperative hemoglobin, hematocrit, urea and creatinine values between two groups. Conclusion: In EVAR and TEVAR applications general anesthesia, regional anesthesia, sedoanalgesia accompanied by local anesthesia can be successfully administered depending on the patient\'s status and the location of the procedure.

Anahtar Kelimeler

• General anesthesia, regional anesthesia, aortic aneurism, endovascular procedures

Aort patolojilerinin endovasküler tedavisinde anestezi yönetimi

Öz

Amaç: Bu çalışmamızda torakal ve abdominal aort patolojilerin endovasküler tedavisinde uyguladığımız anestezi yöntemlerini karşılaştırmayı ve literatür eşliğinde tartışmayı amaçladık. Yöntemler: Çalışmamız aort anevrizması ve aort disseksiyonu tanısı ile endovasküler tedavi uyguladığımız toplam 20 hastanın geriye dönük değerlendirilmesiyle gerçekleştirilmiştir. Hastaların demografik özellikleri, Amerikan Anestezi Derneği (ASA) skorları, laboratuar değerleri, eşlik eden hastalıklar, sigara kullanımı, ejeksiyon fraksiyonu, aort patolojisinin yeri ve tipi kaydedildi. Ayrıca uygulanan cerrahi işlem, anestezi yöntemleri, operasyon sırasında kullanılan kristalloid, kolloid ve kan ürünleri miktarları, anestezi ve cerrahi süresi, komplikasyonlar ve müdahaleler, yoğun bakım ünitesi ve hastanede kalış süreleri ile mortalite oranları kaydedildi. Tüm olgulara standart anestezi monitörizasyonu yapıldı. Bulgular: Toplam 20 (E=15, K=5) olgu çalışmamıza dahil edildi. Olgularımızın 16\'sı ASA 3 ve 4\'ü ASA 4 risk grubundaydı. Torakal endovasküler aort tamiri (TEVAR) uygulanan hastalarımızın tümüne genel anestezi verilirken abdominal endovasküler aort tamiri (EVAR) uygulanan hastalarımızdan 7 olguya rejyonel, 6 olguya genel anestezi ve bir olguya da sadece sedoaneljezi verilmiştir. EVAR uygulanan hastaların 8\'inde HT varken TEVAR uygulanan hastalarımızın hepsinde HT mevcuttu. Gruplar arasında kan ve kan ürünleri transfüzyonu, preoperatif ve postoperatif hemoglobin, hematokrit, üre ve kreatin değerleri açısından istatiksel olarak anlamlı bir farklılık saptanmadı. Sonuçlar: EVAR ve TEVAR uygulamalarında genel anestezi, rejyonel anestezi, sedoanaljezi eşiliğinde lokal anestezi hastanın durumuna ve işlem yapılacak alana bağlı olarak başarılı bir şekilde uygulanabilmektedir.

Anahtar Kelimeler

• Genel anestezi, rejyonel anestezi, aort anevrizması, endovasküler girişimler

Kaynakça

1. Baril DT, Cho JS, Chaer RA, Makaroun MS. Thoracic aortic aneurysms and dissections: endovascular treatment. Mount Sınaı Journal Of Medıcıne 2010;77:256-269.
2. Edwards MS, Andrews JS, Edwards AF, et al. Results of en- dovascular aortic aneurysm repair with general, regional, and local/monitored anesthesia care in the American Col- lege of Surgeons National Surgical Quality Improvement Program database. J Vasc Surg 2011; 54:1273–1282.
3. Gürbüz A, Özsöyler İ, Yıllık L, ve ark. Torakal ve torako ab- dominal anevrizmaların tedavisinde cerrahi ve endovaskül- er cerrahi tekniklerin birlikte kullanımı. Turk Gogus Kalp Damar 2008;16:146-149.
4. Ulucan Ş, Keser A, Kuzgun A, et al. Dev abdominal aorta anevrizmasının endovasküler stent-greft ile tedavisi. J Clin Exp Invest 2012;3:423-425.
5. Ruppert V, Leurs LJ, Rieger J, et al. EUROSTAR Collabora- tors. Risk-adapted outcome after endovascular aortic aneu- rysm repair: analysis of anesthesia types based on EURO- STAR data. J Endovasc Ther 2007;14:12-22.
6. Leykin Y, Rubulotta FM, Mancinelli P, et al. Epidural anaes- thesia for endovascular stent graft repair of a ruptured tho- racic aneurysm. Anaesth Intensive Care 2003; 31:455–460.
7. Lachat ML, Pfammatter T, Witzke HJ, et al. Endovascular repair with bifurcated stent-grafts under local anaesthesia to improve outcome of ruptured aortoiliac aneurysms. Eur J Vasc Endovasc Surg 2002; 23:528–536.
8. Wax DB, Garcia C, Ampbell N, et al. Anesthetic experience with endovascular aortic aneurysm repair. Vasc Endovascu- lar Surg 2010;44:279-281.

9. Huang JJ. Spinal anesthesia for endoluminal abdominal aor- tic aneurysm repair. J Clin Anesth 2002;14:176-178.
10. Bettex DA, Lachat M, Pfammatter T, et al. To compare general, epidural and local anaesthesia for endovascu- lar aneurysm repair (EVAR). Eur J Vasc Endovasc Surg 2001;21:179-184.
11. Baker AB, Lloyd G, Fraser TA, et al. Retrospective re- view of 100 cases of endoluminal aortic stent-graft surgery from an anaesthetic perspective. Anaesth Intensive Care 1997;25:378-384.
12. Aadahl P, Lundbom J, Hatlinghus S, Myhre HO. Regional anesthesia for endovascular treatment of abdominal aortic aneurysms. J Endovasc Surg 1997;4:56-61.
13. Henretta JP, Hodgson KJ, Mattos MA, et al. Feasibility of endovascular repair of abdominal aortic aneurysms with local anesthesia with intravenous sedation. J Vasc Surg. 1999;29:793-798.
14. Hamerlynck JV, Legemate DA, Hooft L. From the Cochrane Library: ultrasonographic screening for abdominal aortic aneurysm in men aged 65 years and older: low risk of fatal aneurysm rupture. Ned Tijdschr Geneeskd. 2008;152:747- 749.
15. Piffaretti G, Tozzi M, Lomazzi C, et al. Complications af- ter endovascular stent-grafting of thoracic aortic diseases. J Cardiothorac Surg. 2006;1:26.
16. Beckman JA, Mehta RH, Isselbacher EM, et al. Branch ves- sel complications are increased in aortic dissection patients with renal insufficiency. Vasc Med. 2004;9:267-270.
17. Hogendoorn W, Schlösser FJ, Muhs BE, Popescu WM. Surgical and anesthetic considerations for he endovascular treatment of ruptured descending thoracic aorticaneurysms. Curr Opin Anaesthesiol. 2014;27:12-20.
18. Knapp J, Bernhard M, Rauch H, et al. Anesthesiolog- ic procedure for elective aortic surgery. Anaesthesist. 2009;58:1161-1182.
19. Lee WA, Matsumura JS, Mitchell RS, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg 2011;53:187–192.
20. Wang SW, Lin Y, Yao C, et al. Comparison of clinical cura- tive effect between open surgery and endovascular repair of abdominal aortic aneurysm in China. Chin Med J (Engl). 2012;125:1824-1831.
21. Borgeat A, Aguirre J. Sedation and regional anesthesia. Curr Opin Anaesthesiol. 2009;22:678-682.
22. Moerman AT, Herregods LL, De Vos MM, et al. Manual versus target controlled infusion remifentanil administra- tion in spontaneously breathingpatients. Anesth Analg 2009;108:828–834.
23. Rapeport DA, Martyr JW, Wang LP. The use of “ketofol” (ketamine-propofol admixture) infusion in conjunction with regional anaesthesia. Anaesth Intensive Care 2009;37:121- 123.
24. De Virgilio C, Romero L, Donayre C, et al. Endovascular abdominal aortic aneurysm repair with general versus lo- cal anesthesia: a comparison of cardiopulmonary morbidity and mortality rates. J Vasc Surg 2002;36:988-991.
25. Gümüş F, Polat A, Farsak B, Alagöl A. Endovasküler Aortik Rekonstrüksiyonlarda Anestezi Yaklaşımı Koşuyolu Kalp Derg 2013;16:25-31.
26. Cao P, Zannetti S, Parlani G, et al. Epidural anesthesia re- duces length of hospitalization after endoluminal abdomi- nal aortic aneurysm repair. J Vasc Surg. 1999;30:651-657.
27. Armstrong RF, Addy V, Breivik H. Epidural and spinal anaesthesia and the use of anticoagulants. Hosp Med. 1999;60:491-496.
28. Zeyneloglu P, Gulsen S, Camkiran A, et al. An epidural he- matoma after epidural anesthesia for endovascular aortic aneurysm repair. J Cardiothorac Vasc Anesth. 2009;23:580- 582.
29. Salman N, Uçar Hİ, Serter T, Yorgancıoğlu C. Endovascular repair of dissecting abdominal aortic aneurism under spinal anesthesia in a patient with pulmonary embolus. Turkish J Thorac Cardiovasc Surg 2011;19:645-648.
30. Ruppert V, Leurs LJ, Steckmeier B, et al. Influence of anes- thesia type on outcome after endovascular aortic aneurysm repair: an analysis based on EUROSTAR data. J Vasc Surg 2006;44:16-21.
31. Horlocker TT, Heit JA. Low molecular weight heparin: biochemistry, armacology, perioperative prophylaxis regi- mens, and guidelines for regional anesthetic management. Anesth Analg 1997;85:874-885.
32. Rigler ML, Drasner K, Krejcie TC, et al. Cauda equina syndrome after continuous spinal anesthesia. Anesth Analg 1991;72:275-281.
33. Lachat ML, Pfammatter T, Witzke HJ, et all. Reprinted arti- cle “Endovascular repair with bifurcated stent-grafts under local anaesthesia to improve outcome ofruptured aortoiliac aneurysms”.Eur J Vasc Endovasc Surg. 2011;42:86-93.
34. Arbatlı H, Yağan N, Demirsoy E ve ark. Abdominal aort anevrizmalarının endovasküler tedavisi. Anadolu Kardiyol Derg 2003;3:115-121.
35. Martin DJ, Martin TD, Hess PJ, et al. Spinal cord ischemia after TEVAR in patients with abdominal aortic aneurysms. J Vasc Surg. 2009;49:302-307.
36. Wiedemann D, Mahr S, Vadehra A, et al. Thoracic endovas- cular aortic repair in 300 patients: long-term results. Ann Thorac Surg. 2013;95:1577-1583.
37. Matsuda H, Ogino H, Fukuda T, et al. Multidisciplinary ap- proach to prevent spinal cord ischemia after thoracic endo- vascular aneurysm repair for distal descending aorta. Ann Thorac Surg. 2010;90:561-565.